Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Encore Healthcare And Rehabi Of Malvern during CMS and state inspections, most recent first.
Failure to Report Abuse Allegations Within Required Time Frame: The facility did not report three abuse allegations within the required 2-hour window. The incidents involved resident-to-resident and staff-to-resident allegations, including threats, physical contact, and a CNA statement to a resident about giving a shot. The Administrator stated she waited to investigate before reporting, despite the facility policy requiring immediate reporting, no later than 2 hours after forming suspicion.
Failure to Complete Behavioral Health Consult Order: A resident with severe cognitive impairment, anxiety, and depression had increased confusion, hallucinations, paranoia, and an episode of physical aggression, leading to an APRN referral for psych/behavioral health services. Nursing documentation noted a mental health referral and a dementia care consult, but there was no evidence the consult was completed. The APRN later confirmed a behavioral health consult order was entered after a UA ruled out a physical cause, and the DON stated the facility could not provide the order and the consult was not followed.
A resident with moderate cognitive impairment was verbally and physically abused by another resident with a history of trauma and aggression. Despite initial verbal threats, the facility did not relocate the aggressive resident until after a physical attack occurred. Staff interviews indicated a lack of awareness and preventive measures to protect the victimized resident.
A resident with a history of falls and severe cognitive impairment sustained bifrontal subdural hematomas after a fall due to the facility's failure to implement a physician's order for a fall mat. Despite the order, the fall mat was not consistently placed, and the resident experienced multiple falls. Staff interviews revealed inconsistencies in implementing interventions, such as keeping the bed in the lowest position. The lack of communication and coordination among staff contributed to the deficiency.
A resident with cognitive impairment and mobility issues fell and sustained head injuries due to the facility's failure to update the care plan with a fall mat intervention. Despite an order for a fall mat, it was not consistently placed or documented, and staff were not adequately informed. The lack of communication and documentation led to the oversight, resulting in the resident's fall.
The facility's dietary department failed to follow proper food safety and hygiene practices. Staff did not wash hands or change gloves after contamination, and food items were improperly stored and expired items were not discarded. Additionally, hot food was not maintained at the required temperature. These deficiencies were observed through staff actions and a review of facility policies.
A dietary aide in an LTC facility failed to serve meals according to the planned menu, using incorrect scoop sizes for pureed diets. This resulted in residents receiving smaller portions than required, affecting their nutritional intake. The aide admitted to not consulting the menu before serving.
A resident with multiple health conditions was involved in an incident where CNAs improperly used a mechanical lift by locking the casters, contrary to the manual's instructions. Despite receiving training, the CNAs believed locking the wheels would prevent movement. The DON confirmed the correct procedure after reviewing the manual.
The facility failed to label an anti-anxiety medication with the open and use by date, as required by policy, leading to the potential administration of expired medication. An LPN was unable to confirm the medication's opening date, and the DON confirmed the medication was past its use date, as advised by the pharmacist.
Failure to Report Abuse Allegations Within Required Time Frame
Penalty
Summary
The facility failed to report allegations of abuse within the required 2-hour time frame for three residents involved in separate incidents that were discovered by staff. In Incident #1, an alleged resident-to-resident abuse event involving Resident #1 and Resident #7 was discovered on March 10, 2025 at 11:30 AM, but the report was not submitted to the state agency until 3:56 PM. The allegation involved Resident #7 threatening Resident #1 after becoming agitated about Resident #1's television volume and light being on. Resident #1 had diagnoses including cognitive communication deficit and recurrent depressive disorder, and a later MDS showed a BIMS score of 15, indicating cognitive intactness. Resident #7 had diagnoses including memory, thinking, and behavior impairment, cognitive communication deficit, anxiety disorder, and depression, with a later BIMS score of 5 indicating severe cognitive impairment. In Incident #2, an alleged resident-to-resident physical abuse event involving Resident #3 and Resident #6 was discovered on May 5, 2025 at 7:30 AM and was not reported until 12:54 PM. The allegation stated that a CNA found Resident #6 in bed with Resident #3 with Resident #6's hand over Resident #3's mouth. Resident #3 had diagnoses including a disorder affecting memory, thinking, and behavior, anxiety, hemiplegia and hemiparesis, and cognitive communication deficit, with an admission MDS BIMS score of 3 indicating severe cognitive deficit. Resident #6 had diagnoses including a disorder affecting memory, thinking, and behavior with mood disturbance, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder, with a later BIMS score of 3 indicating severe cognitive impairment. In Incident #3, an alleged staff-to-resident abuse event involving Resident #4 and a CNA was discovered on April 29, 2025 at 4:00 PM and was not reported until the next day at 11:17 AM. Resident #4 had diagnoses including sensorineural hearing loss and cognitive communication deficit, and an admission MDS BIMS score of 14 indicating cognitive intactness. During interview, the Administrator stated she did not follow the regulation requiring reporting within two hours because she needed to investigate the allegations first. The facility policy stated that all allegations of abuse or neglect must be reported according to state and federal law and that allegations of abuse or serious bodily injury must be reported immediately, but no later than 2 hours after forming the suspicion.
Failure to Complete Behavioral Health Consult Order
Penalty
Summary
The facility failed to ensure staff initiated and completed provider orders for a psychiatric consult for one resident. The resident had a quarterly MDS with a BIMS score of 3, indicating severe cognitive impairment, and diagnoses that included a disorder affecting memory and thinking, anxiety disorder, and depression. Progress notes documented that after an incident in which the resident initiated physical aggression toward another resident, the APRN referred the resident to the psych team because of increased confusion and hallucinations. Nursing notes also documented referral to mental health and noted increased paranoia and confusion at night and on weekends, with a dementia care and mental health consult as a new patient. The record contained no evidence that the mental health or psych team consult was completed. The APRN stated that after ruling out a physical cause for the behavior change with a UA, a new order was entered on 05/12/2025 for a behavioral health consultation for dementia and hallucinations. The APRN also provided a handwritten note listing the new order, but the DON stated the facility was unable to provide the order for the Behavioral Health consult intended for the resident and that the behavioral health consultation was not followed. The LPN Supervisor job description stated that requisitions and arrangements for therapeutic services are to be made per physician orders.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a deficiency. Resident #1, who had moderate cognitive impairment and several medical conditions, was verbally threatened by Resident #2 on two occasions. The first incident occurred when Resident #2 verbally threatened to kill Resident #1 while pointing a finger in their face. Despite this threat, Resident #2 was not immediately moved to another room, and the two residents remained roommates. A second incident occurred when Resident #2 physically attacked Resident #1, hitting them in the face and chest. This attack was witnessed by a CNA, who immediately separated the residents and informed the Administrator. The facility's response to the initial verbal threat was inadequate, as Resident #2 was not relocated until after the second verbal threat and subsequent physical attack. Interviews with staff revealed that Resident #2 had a history of trauma and aggressive behavior, but the facility did not take sufficient preventive measures to protect Resident #1. The Director of Nursing and other staff members were unaware of any specific issues between the residents, and the facility's policy on preventing further abuse was not effectively implemented in this case.
Failure to Implement Fall Mat Order Leads to Resident Injury
Penalty
Summary
The facility failed to implement a physician's order for a fall mat for a resident, resulting in the resident sustaining bifrontal subdural hematomas after a fall. The resident, who had a history of falls and was severely cognitively impaired, had an order for a fall mat to be placed on the right side of the bed due to cognitive communication deficits and a history of falling. Despite this order, the fall mat was not consistently placed, and the resident experienced multiple falls, including one that resulted in a hospital visit and the discovery of hematomas. The resident's care plan indicated a risk for falls, with interventions such as hourly toileting and keeping the bed in the lowest position. However, interviews with staff revealed inconsistencies in the implementation of these interventions. CNAs and LPNs reported that the resident's bed was not always in the lowest position, and the fall mat was not consistently placed on the floor. The MDS Coordinators and nursing staff were not fully informed or coordinated regarding the fall mat order, leading to a lack of proper documentation and follow-through in the resident's care plan. The prior and current Directors of Nursing indicated that there were procedures for updating care plans and informing staff of new orders, but these were not effectively executed in this case. The lack of communication and coordination among staff members contributed to the failure to implement the fall mat order, ultimately resulting in the resident's injury.
Failure to Revise Care Plan Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced a fall resulting in bifrontal subdural hematomas. The resident, who had a history of hemiparesis, hemiplegia, dementia, and multiple fractures, was severely cognitively impaired and required substantial assistance for mobility and personal care. Despite an order for a fall mat to be placed on the right side of the bed, the care plan was not updated to include this intervention, contributing to the resident's fall. The incident occurred when the resident attempted to move from the bed to a wheelchair, resulting in a fall where the resident was found lying on the floor with head injuries. Interviews with CNAs and an LPN revealed that the resident was unable to operate bed controls and had been observed with the bed not in the lowest position. Although a fall mat was ordered, it was not consistently placed or documented in the care plan, and staff were not adequately informed of the intervention. The MDS Coordinators and nursing staff were responsible for updating the care plan but failed to include the fall mat intervention. The lack of communication and documentation led to the oversight, as the order for the fall mat was not effectively communicated to all relevant staff members. The facility's process for revising care plans and ensuring staff awareness of new interventions was insufficient, contributing to the resident's fall and subsequent injury.
Food Safety and Hygiene Deficiencies in Dietary Department
Penalty
Summary
The facility failed to adhere to proper food safety and hygiene practices, as observed during a survey. Dietary staff did not wash their hands or change gloves after contamination and before handling food and clean equipment. Instances included handling food and equipment with contaminated hands or gloves, such as picking up glasses by their rims, placing plates with fingers inside them, and attaching a clean blade to a blender after touching dirty objects. Additionally, food items were not stored properly, with opened boxes of sausage, biscuits, and chicken fried steak left uncovered in the refrigerator and freezer. Expired food items, such as ground cloves and thyme, and undated desserts were also found in storage areas. Furthermore, the facility did not maintain hot food items at the required temperature of 135 degrees Fahrenheit or above. For example, tomato soup was served at temperatures of 121 and 122 degrees Fahrenheit. The facility's policy on hand washing and glove usage, which requires employees to wash their hands before starting work and after touching dirty equipment, was not followed. These deficiencies were identified through observations, interviews, and a review of facility policies, indicating a lack of compliance with professional standards for food safety and hygiene.
Failure to Serve Meals According to Planned Menu
Penalty
Summary
The facility failed to ensure that meals were prepared and served according to the planned written menu, resulting in nutritionally imbalanced meals for residents on pureed diets. During the noon meal service on November 18, 2024, a dietary aide used incorrect scoop sizes to serve pureed cornbread and pureed chicken and dumpling. Specifically, a #16 scoop (1/4 cup) was used instead of the required #8 scoop (1/2 cup) for pureed cornbread, and a #8 scoop (1/2 cup) was used instead of the required #6 scoop (2/3 cup) for pureed chicken and dumpling. The dietary aide admitted to not consulting the menu and consistently using the incorrect scoop size for pureed cornbread. On November 19, 2024, during the breakfast meal, the same dietary aide again used a #16 scoop (1/4 cup) instead of the required #8 scoop (1/2 cup) to serve pureed French toast to residents on pureed diets. The dietary aide acknowledged the mistake and admitted to not checking the menu before serving meals. These actions led to the residents receiving smaller portions than prescribed, potentially affecting their nutritional intake.
Improper Use of Mechanical Lift Leads to Safety Deficiency
Penalty
Summary
The facility failed to ensure that a mechanical lift was used correctly, leading to a deficiency in accident prevention and resident safety. Specifically, the incident involved a resident with Parkinson's, type II diabetes, and Alzheimer's, who required total care for daily activities and was dependent on a mechanical lift for transfers. The care plan indicated the use of a mechanical lift with a green lift pad, and the instruction manual specified that the casters should remain unlocked during lifting. However, during an observation, two CNAs were seen locking the rear casters while using the lift, contrary to the manual's instructions. The CNAs involved in the incident believed that locking the wheels would prevent the lift from moving, despite having received training on the proper use of the mechanical lift. The Director of Nursing (DON) was initially unsure of the correct procedure but confirmed after reviewing the manual that the casters should remain unlocked. The DON also provided documentation showing that one of the CNAs had been trained on the lift, indicating a lapse in adherence to the training provided.
Failure to Label Anti-Anxiety Medication with Use By Date
Penalty
Summary
The facility nursing staff failed to properly label an anti-anxiety medication stored in the refrigerated narcotic box in the 300-hall medication room. The medication was not labeled with the open and use by date, which is necessary to prevent administering expired medication to residents. The facility's policy requires that medications be dated when the manufacturer's seal is broken, and a new expiration date is set, which in this case should have been 60 days from opening. However, the staff did not adhere to this policy, as observed by the surveyor. During the survey, it was found that a resident had an unopened bottle and a second opened bottle of anti-anxiety medication in the locked narcotic box. The opened bottle was not labeled with the date it was opened, and the 'Do Not Use Beyond' sticker was not filled out. The LPN on duty was unsure of when the medication was opened and could not confirm the duration for which the medication was effective after opening. The DON later confirmed that the medication was past its expected use date, as advised by the pharmacist, and it was inappropriate to administer the medication from the opened bottle due to potential loss of potency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Malvern
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbor Oaks Healthcare And Rehabilitation Center | 0.2 mi | ★★★★★ | 0 | 0 |
| The Pines Nursing And Rehabilitation Center | 13.1 mi | ★★★★★ | 0 | 0 |
| The Springs Of Red Oak | 13.1 mi | ★★★★★ | 2 | 0 |
| The Blossoms At Hot Springs Rehab And Nursing Cent | 14.5 mi | ★★★★★ | 0 | 0 |
| Arkansas Health Center | 15.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.